ADHD meds at risk? Unpacking the new executive order, DEA proposal

ADHD medications have been in the news a lot lately, especially stimulants. 

In this bonus episode of Hyperfocus, host and mental health journalist Rae Jacobson talks about two U.S. policy items that could affect people with ADHD.

First, an executive order from February 13 established the “Make America Healthy Again Commission.” The executive order specifically mentions ADHD and the rise in diagnoses and medication usage among children. 

The order also requires the commission to “assess the prevalence of and threat posed by the prescription of selective serotonin reuptake inhibitors, antipsychotics, mood stabilizers, stimulants, and weight-loss drugs.” 

Dr. Andy Kahn, a licensed psychologist, joins Rae to discuss the notion that people with ADHD, especially kids, are overmedicated. 

Plus, Rae discusses proposed regulatory changes for controlled substances, including ADHD stimulants. 

The Drug Enforcement Agency (DEA) issued its proposal on January 17, before the current administration took office. If accepted, the proposed changes would affect telehealth prescriptions for ADHD stimulant medications. The DEA is accepting comments through March 18.

We love hearing from our listeners. Email us at hyperfocus@understood.org.

• All about ADHD medication 

• Full text: White House executive order

• Read the DEA’s proposed telemedicine regulations 

• What happens to my child’s IEP if the U.S. Department of Education closes? 

(0:38) What does the new executive order say about ADHD? 

(4:04) What does “overmedicated” mean today? 

(6:08) On stigma and ADHD

(9:56) What is the new DEA telehealth proposal?

Rae: ADHD meds have been in the news an awful lot lately. It feels like everyone has something to say about them, how they're prescribed, how much they're prescribed, and how easy or not it should be to get them. It's a lot to take in, and it can feel pretty overwhelming. So, we figured this was as good a time as any for our first-ever "Hyperfocus" bonus episode. Let's get to it.

On Thursday afternoon, after Robert F Kennedy Jr., the new Secretary of Health and Human Services was confirmed, the White House issued an executive order establishing the Make America Healthy Again Commission. In it, they specifically mentioned concerns that children are being overmedicated for ADHD. It's one paragraph in a longer order, but it also comes at a time when the DEA, the Drug Enforcement Agency, is considering new rules that would roll back exemptions that made it easier to get ADHD medications through telehealth.

We'll get to that later in the episode. But first, I want to talk about the executive order and this long held idea that we're overmedicating people for ADHD, especially kids. So, after I read this, I figured there was no one better to talk to than Dr. Andy Kahn, who works a lot with families, with kids, with ADHD. So, Andy, thank you for coming on in this very short notice.

I wanted to kind of talk about this conversation. We've been having it for decades. Are kids with ADHD overmedicated? Are they under medicated and how do we fix it? And I feel like in my dream world, this conversation would lead to a discussion about better evaluations, about making sure that the people we diagnose with ADHD actually have ADHD. And then if they don't, they're getting the right treatment, not just a panacea treatment. So, I hope maybe you can take me through this and help me understand a little bit more about why this is such a controversial thing.

Andy: Yeah. And let me start with a disclaimer. So, I'm a licensed psychologist, which means I am not a medical provider. I do not prescribe. I work with families for the last 25 years on navigating and managing ADHD. I myself have ADHD. So, this is an issue that's really close to my heart and clearly close to my clinical background. When we think about treating ADHD, these are ongoing lengthy questions. So, we have an impetus, right? We have something that has triggered another discussion for us. And when we talk about treatment of ADHD, we have to think about what does the research say, what are the gold standards, and what are we seeing.

For each individual child, this can vary pretty widely. So, thinking about your individual child as a listener here, this is going to require some very specific steps which is looking at what are you needing for your child? What are your child's present severity of symptoms? And having a family discussion around what suits you, what is comfortable for you, and what data you may have access to. So, when we bring up an issue like this, Rae, obviously it makes a lot of us concerned because it feels like there's a focus on something that is being done wrong and that there's a question that something isn't being done in an appropriate way.

And I would say that long before this statement was released, these were questions that we were trying to answer. So, today, I think we probably have to talk about what are the ideal ways of approaching the treatment of ADHD. And I think that this has to be the central focus of our conversation.

First and foremost, are kids being overmedicated? OK, this is a very broad question, and the answer is going to be a little unsatisfying, which is, sometimes. When kids are not being monitored well for their services, they're not getting good medical attention and not getting the care on a regular basis they need, there is always the risk of being overmedicated because every child's responses to medications is an individual thing.

Rae: So, Andy, I have a question about the word overmedicated because I feel like it doesn't always mean what it sounds like it means, which is that kids are getting too much of a medication. Are we talking about people who are taking too much medication or people who are taking the wrong medication or who are taking medication when they don't actually need it?

Andy: Yeah. You know, I think a lot of the culture of this and there's a lot of stigma surrounding this, which is that overmedicated, as I historically referred to it as a kid having too much medication is that they have too much medication for what we're trying to treat. I think what we're seeing in a lot of these documents is talking about the idea that too many kids are getting medication. And I think that given the quality of the assessments that are available and how we define what ADHD looks like in the real world, you know, that's the concern I think we're coming up against.

And that there's some sort of movement to either diagnose less kids or to provide less treatment for ADHD, which comes across as a bit scary. And a lot of my families have talked to me about this. They're worried about being able to treat their children who have been appropriately diagnosed with ADHD. So, I think that that's one of the things that a lot of people are concerned with right now.

Rae: Is this something that also has to do with the shortage of ADHD medication, you know, for what, 2 or 3 years now, we've had a shortage. A lot of people haven't been able to access medications, even with appropriate diagnoses. Is that something that's bringing up fear for the families that you see?

Andy: Well, I think it's magnifying that fear. I think the ongoing challenge is that people, families are fighting routinely to get access to medications that they know their children need and benefit from. And they've already been in this process where their children are effectively engaged in treatment. So, to feel like that that could be limited to them or could be under further scrutiny is a really scary thing because there are a lot of kids getting what they need through their treatment providers, whether it be for the combination of medication and therapy and through services and other environments.

So this is definitely, for many families, they're coming to me and saying, "I'm afraid that my child's services are under attack and I'm concerned about how this is going to be navigated."

Rae: It's a scary time in a lot of ways for that sort of thing. I wonder, like, because, you know, you and I both have ADHD. We've always heard about ADHD medication, which itself carries a stigma almost separate from the disorder but that sort of reflects onto the disorder, as a provider who helps people find treatment for ADHD, what do you think would combat that stigma? Like, is it better evaluations? Is it a different type of conversation about the disorder itself? Is it helping people understand a little bit more about what ADHD medication does? What would help?

Andy: I think at the core, the first step is always addressing what we have in terms of shortages in not just medication, but access to qualified and good quality assessments. If we're getting access to good quality assessments and there's a gold standard for how we do this, then as people are diagnosed, they don't have to continuously defend themselves from being said, "Oh you know, there's too much treatment being provided." And I think we are paying a bit of a price for this.

During Covid, a lot of assessments were provided that maybe weren't to the standard of what folks would normally like to see. And simultaneously, we saw a large increase in folks being diagnosed and the medication production not keeping up. So, I do think that that's a common factor. I think the other factor that really needs to be evaluated is how are we looking at the gold standard of care for ADHD?

Are we providing enough support to get clinicians available to kids where they live and where they reside to get access to quality clinicians who know how to support skill building, managing the emotional impacts, and helping them develop skills that are essential for them to thrive with their difference with ADHD? In the absence of those supports. What we see is an overemphasis on people in the media and in other outlets on medication as being what we're doing to treat ADHD.

Medication is part of the process of treating ADHD. So, if you can't get access to other supports, it's going to feel, it's going to get magnified in terms of how people think about it. And I think for me, that's a big concern. I'd love to see more investment in getting clinicians accessible to kids and families wherever they are in our country. And that was one of the benefits that we saw in the telehealth movement that came about during Covid.

And I treat kids, for example, across many states right now because I'm certified to do so. But these families are fighting to get access to services. They want to get the best care for their kids. And it's not regularly accessible and it's not financially feasible. So, this becomes a challenge for so many families.

Rae: That's very well said and very helpful. Andy, thank you so much for coming on the show and also coming on like ready and so able to talk about stuff that means so much to so many families.

Andy: Sure. It's really an anxiety provoking time. And I think that we have to continuously provide good evidence-based information. We have to continue to get people to think about the stigmas around ADHD so that people like ourselves who have identified "This is part of who we are. This is part of how we function," that we can continue to advocate for people getting the access to the best care and to increase access to that care for all folks.

Rae: Like Andy said, there's a lot we can do to support kids with ADHD that doesn't involve medication, though medication is an important part of managing ADHD for a lot of people. Supporting kids means early evaluation and services through the school system. IEPs and 504 plans that can help kids access the resources that they need to thrive. But potential cuts to the federal Department of Education and a new lawsuit that seeks to get rid of Section 504 of the Rehabilitation Act of 1973 could make it a lot harder to access these services.

So, now I want to touch on some of those proposed changes we were talking about at the top of the episode. You'll see me look down a lot, like I said before, because I am working off of notes here. So, first, what's going on? So, the DEA is proposing regulatory changes that would establish a new system for how doctors prescribe controlled substances like ADHD medications via telehealth. These changes aren't new. They were proposed on January 17th before the old administration left office.

The proposed changes would require anyone who prescribes a controlled substance, including people who prescribe ADHD medications, to obtain a special registration from the federal government and to be in the same state as their patients. Prescribers would also need to make sure that on average, less than 50% of their total prescriptions for Schedule II drugs are provided via telehealth. These Schedule II drugs are, and this is from the DEA website, ones that have clinical value, but also a high potential for abuse like ADHD stimulants or opioids.

So, one of my biggest questions about this was how is it different from what's going on now? What do these changes actually mean? So, what I learned is the current telehealth rules were introduced by the Trump administration in March of 2020 with the aim of making it easier for people to access care at home during the pandemic. These Covid era rules were exemptions to something called the Ryan Haight Act, a 2008 law passed in response to a teenager who overdosed on Vicodin. The DEA found that Ryan had ordered the drugs from a doctor that he never saw in person and had them delivered by an online pharmacist.

These temporary exemptions are set to expire at the end of 2025, which is one of the reasons we're talking about this again now. So, why is the DEA proposing these changes? The agency says the goal is to keep some of the flexibility offered by the Covid era exemptions while providing safeguards to help keep people, well, safe, and to prevent drugs that are prescribed legally from finding their way into more illicit markets.

The agency lists a number of reasons, including one specific to ADHD. They say that the relaxed telehealth rules during Covid, and I quote here, facilitated the emergence of concerning business models. What they mean when they say this are companies like Done, which positioned itself as a digital health company serving people with ADHD. Here's what the Justice Department has to say about what Done actually did.

The Done founder and clinical president, quote, allegedly obtained subscribers by targeting drug seekers and spending tens of millions of dollars on deceptive advertisements on social media. They also allegedly intentionally structured the Done platform to facilitate access to Adderall and other stimulants, including limiting the information available to Done prescribers, instructing Done prescribers to prescribe Adderall and other stimulants, even if the Done member did not qualify, and mandating initial encounters be under 30 minutes. That means they only saw a provider for less than half an hour.

The founder and clinical president are now facing federal charges of conspiring to commit health care fraud for allegedly arranging the prescription of 40 million pills and generating over $100 million in revenue.

So, telehealth, not all good, not all bad. As a person with ADHD, I've used telehealth to get my medication before. It's really useful for me. I have a hard time, say, making it on time to doctor's appointments, making doctor's appointments at all, and making time to make phone calls. I know I'm not alone in this. The hoops you have to jump through to get the medication that you need, especially during the shortage, are incredibly difficult for people with ADHD. And telehealth took some of that pressure off. Is it a perfect system? No. But for a lot of us, it's been really useful.

And I'm not the only one who's concerned. Like Andy mentioned, a lot of families and providers are concerned that conversations like these could lead to changes that make it more difficult to access medication or exacerbate the stimulant medication shortage that people with ADHD have been facing for years. This is especially serious for people who live in rural areas or places where access to health care is limited. According to the CDC, 1 in 5 Americans lives in a rural area, and telehealth can help reduce health disparities by increasing access to timely, high-quality health care.

So, what's happening now? Right now? Nothing. The DEA has opened a commenting period, which ends on March 18th, and I thought it would be interesting to hear a little bit about what people are saying in the comments.

First, some people write in supporting the rule like this nurse practitioner: "I've observed hundreds of nurse practitioners rushing to obtain licenses across multiple states. Not out of his desire to serve patients, but to maximize their patient load and income through private telehealth services. What was once a noble service has developed into a profit-driven industry. It's not uncommon to see psychiatric nurse practitioners managing 30 to 40 patients per day."

"This is not sustainable, nor does it prioritize the well-being of patients. How can anyone provide quality mental health care under such conditions? The focus has shifted from patient care to financial gain, and I've even encountered individuals who boast about their multi-figure earnings based entirely on the back of this flawed system."

Others write in to share worries. Concerns over access to ADHD care is a major theme in the comments. Many in rural areas, like we said, are particularly worried. Quote, "As someone diagnosed with ADHD who depends on telemedicine to access my prescribed Schedule II medication, a medication that lets me function as a productive adult, I urge the DEA to abandon its catastrophic in-person mandate. This rule would destroy the care stability I've built over three years and inflict unnecessary suffering on millions of Americans managing chronic conditions."

"Living in rural Montana, my nearest ADHD specialist is 248 miles away, and others like me have just begun to rely on the convenience and accessibility of telehealth."

Quote, "Telehealth has become an essential avenue for obtaining prescriptions with over half of ADHD medication prescriptions being written through these virtual appointments. This rule will only increase the strain on ADHD patients, pushing many into a cycle of disorganization and frustration."

Well, that concludes our first-ever "Hyperfocus" bonus pod. If you have any questions or comments, you just want to share how you feel. You can leave a comment below or write to us at hyperfocus@understood.org.

"Hyperfocus" is made by me, Rae Jacobson, and Cody Nelson. Our video producer is Calvin Knie. Our music comes from Blue Dot Sessions and Justin D. Wright mixes the show. Ash Beecher is our supervising producer. Briana Berry is our production director and Neil Drumming is our editorial director.

This show is brought to you by Understood.org. Our executive directors are Laura Key, Scott, Cocchiere, and Seth Melnick. Understood is a nonprofit organization dedicated to empowering people with learning and thinking differences like ADHD and dyslexia. If you want to help us continue this work, you can donate at understood.org/give